Human factors researchers with a nursing background (HF team) supported a quality improvement project piloting new digital whiteboard and virtual nursing technology at a hospital within a mid-Atlantic health system. The digital whiteboards included information for patients, families, and care teams such as patient goals, nutrition status, and contact numbers. Displays were integrated into the TV screens in patient rooms. The digital whiteboards also integrated with telehealth software to enable virtual nursing admissions and discharges, a care model that has become increasingly adopted. The HF team assessed user experience and identified opportunities for optimization. A multidisciplinary implementation team then facilitated making the recommended changes.

The HF team conducted a contextual analysis including a focus group, onsite observations, and interviews with nurses and patients. The focus group included three patient representatives from the health system’s patient and family advisory council for quality and safety. Focus group members provided feedback on the user interface design of the digital whiteboard displays. The HF team also conducted observations and interviews at the pilot hospital. The team observed five nurses, five patients, four patient care technicians, and one virtual nurse interacting with the technology. During observations, semi-structured interviews were conducted to understand the user experience.

Nurses and patients were pleased with the digital whiteboard technology, which is consistent with existing literature studying the impact of virtual care. Nurses were satisfied with the ability to conduct virtual admissions; however, last-minute changes to discharge instructions and patient cognitive status sometimes required the virtual nurse to request the assistance of the primary nurse. Patients expressed that informational screens were too text heavy, volume levels were inconsistent and hard to adjust, and they were not always aware when a call from the virtual nurse was coming in. Nurses and patient care technicians expressed a desire for more formal training on how to use the digital whiteboard and receive updates when the technology was changed or upgraded. Based on the feedback, several changes are being made prior to continuing the rollout of the digital whiteboard, including developing formalized training, reducing the reading level and amount of text on informational screens, and changing the default settings on the volume control. The valuable insights gained in this evaluation reflect the impact of leveraging multidisciplinary implementation teams to identify opportunities to improve patient and clinician experiences and support integrating human factors methods into the decision-making processes when evaluating new technology for implementation in healthcare settings.

Background: Registered nurses are the core communicators of patient status within inpatient settings, channeling and receiving critical information across complex care teams. Secure messaging through electronic health records (EHR) allows nurses to communicate directly with care team members via instant messaging without external tools such as pagers. However, its growing popularity may increase clinician cognitive burden from interruptions, multitasking, and generally higher volumes of messages. Artificial intelligence (AI) tools may help in the prioritization of urgent messages as well as provide a way to identify categories of free-text messages sent within an organization.

Methods: In September 2023, initial messages sent from nurses to providers via secure chat were extracted and de-identified. Each message was reviewed and labeled by pairs of physicians and pairs of nurses based on their urgency. The first round of review contained 150 messages that were labeled based on the desired response time for that message (<1min: emergent, <5min: urgent, >5min: non-urgent). Disagreement within pairs was resolved through group consensus, with the more urgent label chosen if discordance between doctor and nurse pairs existed. The labels were used to generate a prompt for GPT4 and themes for each message class. Model performance was refined through iterative rounds of human labeling and its final prompt was used to update the themes found within each message type.

Results: In round one, doctor-nurse agreement was 70%. After the first round of labeling, a prompt was developed to use ChatGPT to label messages. When this prompt was tested on the first round of human labels, it initially achieved 90% accuracy on emergent messages. After human voting on discordant labels, accuracy increased to 96% (17/42 human labels were overturned in favor of GPT4). The model was re-tested after prompt revision, resulting in 98% accuracy labeling emergent messages from the original group. The updated model classified a new set of 400 human-labeled messages on a separate testing set, achieving 93% accuracy on labeling emergent messages. Additional analysis phases are underway.

Discussion: Nurses and physicians agreed on the urgency of messages for a majority of the instances of review. As the GPT4 model was tuned, its ability to label emergent messages similarly to clinicians improved. By learning to classify messages as emergent, urgent, and non-urgent, future technologies could help clinical teams in a myriad of ways. Secure message analysis may provide clinical informaticists valuable information on EHR tool utilization and highlight improvement areas. It may aid nursing leaders and bedside staff in the reinforcement of appropriate communication methods for various clinical issues. Future research could explore real-time AI analysis of secure messages to suggest priority routing or alternative communication methods like phone calls.

Conclusion: This project demonstrated that GPT4 can effectively classify secure message urgency comparable to human clinicians. The use of AI categorization in secure chat analysis could help discover patterns of usage, areas for improvement, and training opportunities. Future research may establish ways to improve communication efficiency and reduce cognitive burden on healthcare providers.

This poster will discuss the implementation of a custom SQL dashboard for outpatient practices across an enterprise large academic medical center to support performance improvement efforts. The primary objectives were to reduce manual effort in creating improvement graphs, automate processes, ensure consistency with electronic health record (EHR) data, and minimize data delays.

With the decommissioning of an outdated legacy dashboard tool and the burden of existing manual procedures escalating, this project responded to the necessity for a sustainable, standardized solution. Efficient data management strategies were crucial. The project utilized standard data display methods, used summarized EHR data for consistency, and addressed scalability issues by incorporating custom SQL queries and a custom database lookup table. The project delivered a dashboard with enterprise-consistent formatting, monthly and quarterly data summarization levels, trending analysis, and performance comparison against targets. This improvement-focused interactive tool allowed view customization and enhanced analysis capabilities for regions, departments, and clinicians. Results indicated improvements in key metrics (most recent results will be shared) and positive qualitative feedback from users, validating the effectiveness of the initiative.

Learning objective: 80% of participants will be able to recognize essential factors and employ strategies to address technical hurdles inherent in managing extensive volumes of electronic health record data utilized in dashboard creation.

Sano and Alexander (2019) highlight the necessity for healthcare teams to seamlessly transition from electronic health records (EHR) to paper workflows to ensure effective care and patient safety. Compliance with national downtime drilling standards, as mandated by The Joint Commission (TJC), and adherence to the doctor of nursing practice (DNP) project site's policies, which require quarterly downtime drills, underline the importance of this quality improvement project.

This project aimed to optimize nursing performance during EHR downtime at a local Midwest clinic. A needs assessment revealed that only 18% of departments completed downtime drills in Q3 of 2023, with 35% having at least one documented drill, and the family medicine department had not completed any drills for the year. The project's objectives were to develop and implement a downtime drilling protocol for the family medicine department using the CLEAR (check, locate, establish, activate, recover) checklist as a framework and to evaluate the intervention's impact on the nursing team's readiness, efficiency, and satisfaction.

The methodology included a needs assessment, scoping literature review, and theoretical framework analysis to design the intervention. This intervention had three components: baseline knowledge survey and education session, mock downtime drill, and post-knowledge check and satisfaction survey. Using the plan, do, study, act (PDSA) cycle, the project incorporated iterative adjustments based on participant feedback and collected data.

The results showed that the family medicine nursing team correctly utilized the CLEAR checklist 98% of the time, demonstrating high competency. Post-workshop knowledge check scores improved by 13.3%, indicating a better understanding of downtime procedures, and satisfaction scores increased by 16.6%, reflecting a positive perception of the workshop's value. The discussion emphasized the intervention's strengths and limitations, suggesting that using the CLEAR checklist enhances preparedness and response capabilities, as well as confidence and satisfaction among nursing staff. However, it also identified barriers such as communication challenges, resource availability, and scenario variability that need addressing.

The project concluded that the CLEAR checklist effectively guided downtime drilling, improving preparedness and response. Future research should evaluate the intervention's impact on patient safety and care quality and explore scalability across different settings and departments.

Lessons learned: Effective training tool: The CLEAR checklist was effective, helping nurses navigate downtime drills with clarity and precision. Team-based approach: Team-based drills revealed real-time operational barriers, highlighting the importance of routine, scenario-based drills. Knowledge retention: Hands-on downtime drill experience aided knowledge retention, evidenced by slight improvements in pre- and post-knowledge check scores.

Strengths: Enhanced preparedness: The project enhanced preparedness by showing nurses how to complete team-based downtime drills using an evidence-based tool customized to departmental needs. Identification of barriers: Drills with various scenarios helped identify and address barriers, optimizing workflow efficiency during actual EHR downtimes. High utilization rate: The high rate (98%) of correct checklist utilization demonstrated its ease of use and reliability.

Limitations: Survey design: The satisfaction survey design might have inflated average scores due to a potential response bias. Only two out of six participants from one team completed the satisfaction survey. Limited satisfaction data: The limited data on satisfaction scores from one team affected the overall assessment of participant satisfaction.

Next steps: Extend initiative: Expand the downtime preparedness initiative to other departments within the clinic and eventually the entire healthcare organization. Customize the CLEAR checklist to each department's needs and conduct similar baseline assessments, workshops, and evaluations. Enhance drill realism: Improve downtime drills' realism and effectiveness by incorporating advanced simulation techniques like role-playing and real-time problem-solving to closely mimic actual downtime scenarios. Develop training modules: Create comprehensive training modules based on feedback and identified knowledge gaps, including detailed videos and interactive modules. Ensure all staff, including new hires, receive thorough downtime procedure training. The project successfully optimized nursing performance during EHR downtime by implementing a structured, team-based drilling protocol using the CLEAR checklist. The high checklist utilization rate and positive satisfaction scores indicate the protocol's value and potential for broader adoption, enhancing organizational resilience and preparedness for unforeseen disruptions.

Completion of pain screening and assessment for all patients supports the Joint Commission standard to have a process in place to evaluate, treat and/or refer patients for pain treatment. Currently, our hospital-based institutional policies for outpatient clinics require a pain screen to be completed during patient office visit evaluations. Additionally, a pain assessment should be conducted for any positive response to a pain screen.

Currently, medical office assistants (MOAs) are not allowed to conduct clinical assessments. The existing pain screen included assessment questions and there was no clear delineation between screening and assessment. This allowed the MOA to conduct an assessment of pain which is not compliant with their scope of service. By redesigning and implementing a new pain documentation tool, we planned to decrease MOA completion of pain assessment components in the physical medicine and rehabilitation (PM&R) clinic from 100% baseline to 5% post-implementation (November through December 2023).

Through reviewing current workflow practices and policies and by conducting research/brainstorming sessions on our electronic medical record (EMR) functionality, our informatics team, with the assistance of the EMR team, was able to develop a new pain assessment tool. Once the tool was tested and presented to several clinical practice committees and policy/operations teams, the tool was implemented across all clinics at the organization. Additional resources were provided for clinic leadership, such as a tip sheet for the new workflow and a documentation compliance report that the clinic manager could run ad hoc. With the new pain documentation tool available to clinic staff, we began gathering data to review the efficacy of the tool in the PM&R clinic.

Overall, the creation of a new pain assessment tool has eliminated the occurrences of MOAs inappropriately completing pain assessment questions. However, there was a reduction in the number of pain screens that were being completed for office visits across the organization. Therefore, an additional gap analysis can be used to investigate the reduction of pain screens for office visits.

In conclusion, nurses now have access to a tool that allows them to collect valuable pain evaluation data in a standardized format that is easily accessible within the EMR and the MOAs are no longer inadvertently stepping outside of their scope of service.

Telephone triage provides patients with an evaluation of symptom acuity along with care advice to support their health status. A functional, effective triage system can contribute to the organization’s goals of increasing patient safety, improving quality outcomes, decreasing adverse events, improving patient satisfaction, and decreasing hospital visits.

The current state of the nursing triage workflow in our ambulatory care clinics was observed by the triage nurse educator and findings were reviewed with the clinical workflow informaticist team and the nurse triage council (NTC). These findings showed that there is a lack of understanding of the nurse triage tool, an underutilization of the triage function, a lack of standard triage documentation, and confusion when reviewing nurse triage notes. To improve documentation of triage telephone encounters a pilot ambulatory care clinic was selected with a goal to reduce symptom-based telephone encounters by 10% and improve reason for call documentation.

Several interventions were implemented to reach our goal. These include revamping triage education classes and increasing class offering frequency, bringing back onboarding triage classes to in-person to increase participation and engagement, manual chart auditing on documentation and reviewing findings with staff, providing triage data and reason for call resources to clinic leadership, updating triage workflow and documentation process, and sharing changes and updates with staff at department level and council meetings. The baseline average for symptom-based telephone encounters was 42. The average for post-implementation was 86 encounters. The percent change is 107%. The average percent of “blank” reason for call for telephone encounters reduced by 2% from June 2023 – January 2024. The 10% target was not met due to more accurate labeling of reason for call for telephone encounters. Our post-implementation data shows an increase in nurse triage encounters and a decrease in "blank" telephone encounters. This can be attributed to a better understanding and use of the nurse triage documentation tools and improvement from non-clinical staff labeling symptom-related calls by adding "assessment" as the reason for call.

Utilizing nurse triage tools can be correlated to preventing unnecessary emergency room (ER) visits, preventing delay in care, preventing duplicate diagnostics, and improving patient experience. Improving nursing documentation can help prevent liability risk and potential implication to the institution. For next steps, resources and tools the clinic can utilize to increase the correct labeling of nurse triage encounters include development of standard operating procedures (SOP) on clinic-specific expectations for nurse triage utilization. Additional measures to increase nurse triage tool usability include continuing documentation audits to ensure accuracy, adding training and e-modules for telephone triage utilization with the triage nurse educator, and increasing provider inclusion in the nurse triage education.

Purpose: The purpose of this quality improvement project was to reduce the overuse of telemetry monitoring by creating a custom electronic health record (EHR) assessment that assists the nurse to follow a nurse-driven telemetry discontinuation protocol, based on American Heart Association (AHA) guidelines. Keeping patients on telemetry without clinical justification may lead to prolonged patient discomfort, unnecessary monitoring and documentation, reduced resources during telemetry surges, and increased alarm fatigue. In a prior study, a nurse-driven telemetry discontinuation protocol based on AHA recommendations reduced the number of hours patients were kept on telemetry beyond clinical indication without an associated increase in rapid response or code calls. Technology solutions, such as the use of best practice advisories, have resulted in the reduction of unnecessary telemetry monitoring and contributed to cost savings.

Description: Using a plan-do-check-act framework, nursing informatics, quality improvement specialists, and clinical nurses created a custom EHR assessment tool to aid clinical decisions related to an AHA-based nurse-driven telemetry discontinuation protocol in a hospital in Northeastern New Jersey. This assessment is comprised of three new required queries: 1) Did the provider agree to the discontinuation criteria? 2) Does the patient qualify for removal of telemetry based on the discontinuation criteria? 3) Reason discontinuation criteria not met? Depending on the responses to the queries, prompts are generated for nurses to take specific actions. After providing education on the new EHR telemetry assessment to the nursing staff of a cardiac/telemetry and medical/surgical unit, data on telemetry utilization measured by the number of days on telemetry past clinical indication was collected for three months and compared to the three months before the trial.

Evaluation/outcome: In the first half of 2023, patients were on telemetry 10,719 days past clinical indication, with an estimated cost of $450,000 to the organization. The total days on telemetry past clinical indication decreased by 26% during the trial period compared to the three months prior to the intervention, saving an estimated $28,000. Based on these positive outcomes during the trial period, the telemetry assessment tool has been implemented to additional inpatient telemetry units. Project results provide further support for using clinical decision tools in the EHR to encourage evidence-based practice.

This presentation will discuss the innovative actions taken by interdisciplinary teams at an academic medical center to address contingency planning deficits identified in a SAFER assessment conducted in 2021-22. The ANIA SAFER toolkit guided the corrective action journey, including innovative training approaches, downtime drills, and business continuity technology process improvements across interdisciplinary teams.

The presentation will share various qualitative and quantitative methods used to measure progress, such as downtime kit readiness status, downtime education completion, and downtime escape game leader board. The presentation will also explore strategies and tactics that can be used by other organizations to improve their readiness for downtimes and disasters. The objectives of the presentation include analyzing approaches used to restructure the BCA process, exploring innovative approaches for downtime readiness tools and training, describing the key elements in a downtime drill, and sharing obstacles encountered and outcomes achieved.

The presentation concludes by suggesting the need to partner with the EMR vendor to develop plans for a catastrophic downtime and a plan for writing and filling prescriptions when the EMR is down around current federal guidelines for e-prescriptions. The Kotter model was used to guide the change process, with a focus on increasing the sense of urgency and building the guiding team. The presentation will share the innovative approaches used for downtime readiness tools and training, including gamification of learning tools for staff education to replace the standard learning module. The presentation will also discuss BCA readiness, which was two pronged, including assuring that each area had access to a BCA device streamlining the process to add, move, and remove a BCA. With this, the goal was access and ability to print the necessary downtime reports within 30 minutes. The presentation will share the obstacles faced and tactics used to navigate through them, including a comprehensive assessment of BCA devices in every location to assure compliance with guidelines and dynamic monitoring of BCA devices to assure they remained online. The presentation will also discuss the downtime readiness drill, which was minimally invasive to patient care and produced valuable insights for leaders into opportunities for actions to take toward downtime readiness. The presentation will share lessons learned and recommendations for future drills. The presentation will conclude by sharing quantitative and qualitative outcomes and inspiring other organizations to improve their downtime readiness.

Evidence demonstrates that nursing informatics (NI) operates in close collaboration with the department of information technology (IT), guided by overarching strategic goals. However, the non-traditional approach is more focused on bedside nursing practices, aligning with the strategic goals and initiatives of nursing leadership. In an acute care community hospital, the NI functions in tandem with nursing leaders, jointly planning, designing, educating, and implementing nursing programs and technology. These collaborative initiatives significantly enhance the quality and safe delivery of patient care. Clinical inquiries, such as quality improvement and evidence-based practice, are methodologies used to enhance patients' and nurses' outcomes, as well as patients' satisfaction and positive experiences. For instance, optimizing the EPIC brain has reduced the lack of adherence to standard documentation in accordance with regulatory requirements. It has also enhanced safety by ensuring the timely implementation of all providers' orders, including medications. In response to the growing concerns about workplace violence, the NI has played a pivotal role in collaborating with IT and security to review and select a cost-effective and efficient staff duress system. This wearable device is set up for each nursing staff and is considered part of the uniform.

Evidence has consistently shown that the role of NI as a nursing liaison to IT significantly improves problem identification, analysis, and resolution. The restructuring of IT and NI framework significantly increased positive communication, collaboration, team building and decision-making. This structure supported the common goals and processes driving positive changes in the health care organization, inspiring and motivating all those involved.

From a bedside perspective, the value of NI is evident in the increased confidence it instills in nurses for more efficient problem-solving with IT. With the visibility of NI at the bedside, nurses are more engaged and empowered to discuss problems and propose solutions that can alleviate the burden of documentation. NI facilitates the timely reporting of nursing device issues, allowing nurses to spend more time with their patients, thereby enhancing staff satisfaction. Nursing informatics (NI) also serves as a valuable resource for the Joint Commission, providing guidance in navigating electronic health records (EHR), policy, procedure, protocol, and guidelines.

From an organizational perspective, NI serves as an advisor and reports any organizational issues and plans for resolutions with either short- or long-term approaches. There is NI visibility at the nursing leadership level, unit shared governance, and council meetings. NI is also involved in nursing general orientation, externship program, nursing residency program, and recruitment activities. The information sharing from bedside to the leaders and educators enhances the effective ways of teaching nurses in a timely manner leading to successful outcomes. Another example of the nursing organization program is the use of virtual nurse for patient admission and discharge. This program was initiated by executive leaders to alleviate documentation burden and redirect time to patient care. The NI served as a vital key participant in the planning, designing, implementing, evaluating, and educating nurses.

Purpose: The clinical informatics externship program is intended for clinical nurses interested in learning more about or pursuing a career in nursing informatics. The program provides an opportunity to learn in a real-world work environment, earn CNE credits, and develop professional relationships with their clinical informatics colleagues.

Background/significance: Clinical nurses typically have limited exposure to informatics unless they have received formal education for it or are involved in network councils. This program provides them with valuable insight into how changes are implemented in the network and the crucial role of clinical informaticists in driving those changes. Moreover, they are given the opportunity to work with CI mentors on a project aimed at resolving a workflow issue that they had witnessed or encountered in their respective areas.

Methods: A total of 33 applicants applied for the third iteration of the CI externship program. Each application underwent evaluation based on completeness, clarity of responses, interest in informatics, professional development plans, identification of workflow issues, the current and organized nature of the applicant's resume, and the level of manager support. Following the evaluation, the applicants were narrowed down to six clinical nurses from different departments interventional radiology, emergency department, pediatric outpatient office, NICU, cardiovascular/tele unit, and ICU.

The externs participated in both virtual and in-person education sessions, covering topics such as clinical informatics theory and applications. This included discussions about the clinical informaticist role, hardware and software implementation, time management, security and privacy, innovation, project management, downtime, system development, and professional development. They gained insight into the individual journeys of clinical informaticists in the department and the projects with which they were involved. Additionally, they had the opportunity to hear from speakers from the IT and medical informatics departments with which CI collaborates.

Results: The CI externs each worked on projects with their mentors and presented them to the CI team on the last day. Some were able to implement changes on their unit, while others presented on proposed changes that were not approved by network informatics committees. The externs submitted anonymous evaluations at the end of each day to help improve the program. At the conclusion of the program, they took part in an exit survey where they shared their experiences, the program's strengths and weaknesses, and overall thoughts. All six externs reported gaining a better understanding of the field after attending the program, and they indicated that they were "somewhat likely" or "very likely" to recommend the program to others.

Conclusions/implications: The externship immersed dedicated nurses in an intensive journey of professional growth. Collaborating closely with seasoned clinical informaticist mentors, they undertook projects aimed at optimizing electronic health records and streamlining clinical workflows. The program empowered them to learn about the process of project implementations and the role of clinical informaticists throughout them.